374603762-12-12-2023-08-AS-DCOA-CYG5SQ-20231212191309

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374603762
Report Date: 12/12/2023
Date Signed: 12/12/2023 08:12:59 PM

Document Has Been Signed on 12/12/2023 08:12 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME:	MOM'S HOUSE		FACILITY NUMBER:	374603762
ADMINISTRATOR:	MCINTYRE, CARMEN ROSA		FACILITY TYPE:	740
ADDRESS:	8596 ATLAS VIEW DRIVE		TELEPHONE:	(619) 562-5370
CITY:	SANTEE	STATE: CA	ZIP CODE:	92071
CAPACITY:	6	CENSUS: 3	DATE:	12/12/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Licensee Carmen McIntyre		TIME COMPLETED:	01:10 PM

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Licensing Program Analyst (LPA) Debbie Correia conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was greeted by Licensee McIntyre, identified themselves to, and discussed the purpose of the visit to Licensee McIntyre.

According to the facility’s license, the facility has a maximum capacity of four (6) residents, of which one (1) may be bedridden, and has a waiver for (3) residents who receive hospice care. During today's inspection, there were a total of three (3) residents in care, of which 0 were bedridden and 0 were receiving hospice.

LPA, accompanied by Licensee McIntyre, toured the interior and exterior of the facility, and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows and screens, toilets, and showers were in working order. Extra linens, hygiene supplies, and Personal Protective Equipment (PPE) were present. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. The facility’s ambient internal temperature was compliant, at 71 F. The facility's hot water temperature for faucets used by residents measured at 118.4 and 110.4 F.

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Debbie Correia	TELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:	DATE: 12/12/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: MOM'S HOUSE	FACILITY NUMBER: 374603762
	VISIT DATE: 12/12/2023

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There was no pool or large bodies of water on the premises. According to the licensee, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were working. Fire extinguisher(s) were serviced within the last 12 months. First aid kit(s) and first aid manual were complete and readily accessible. Required licensing postings were observed in visible areas of the facility.

LPA interviewed multiple staff, and LPA reviewed staff and resident records/files. The interviews did not raise any licensing concerns. The resident and staff files contained the required documents. Confidential records, medications, and toxins were inaccessible to residents in care..

During today's visit, no deficiencies were observed. An exit interview was conducted with Licensee McIntyre, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) will be provided.

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Debbie Correia	TELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:	DATE: 12/12/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2023

LIC809 (FAS) - (06/04)

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